Managerial Decision-Making of Nurses in Hospitals: creation and validation of a simulation scenario

Abstract Objective: to build and validate a clinical simulation scenario on hospital nurse managerial decision-making competence for undergraduate nursing students. Method: a descriptive and methodological study was carried out in a higher education institution, with the participation of 10 judges and five players. To do so, the conceptual simulation model proposed by Jeffries and standards of the International Nursing Association for Clinical Simulation and Learning were used to prepare the scenario and the checklist. Results: the scenario was called “Managerial decision-making of nurses in the face of adverse events in a hospital”. The scenario script and checklist were built for validation. The checklist was face- and content-validated. Afterward, judges used the checklist to validate the scenario, which, in its final version, was composed of Prebriefing (seven items), Scenario in Action (18 items) and Debriefing (seven items). Conclusion: the scenario proved to be a teaching strategy that anticipates the reality of future nurses, bringing them the self-confidence to perform their activities and helping them to act critically and reflectively during decision-making processes.


Introduction
Scientific evidence has shown that a hospital is a place of health care that requires trained nurses to deal with different situations. In hospitals, the deficit of professional managerial skills is associated with factors that negatively affect the outcomes of users (1) . In this scenario, nurses have played the role of manager of their team, thus requiring different knowledge to meet the demands of the institution, thus promoting excellence in care.
Following this line of thought, the development of specific professional skills in nursing management should be considered for the daily professional practice of nurses in a hospital unit (2) . Given this, the training of these professionals should include discussions also focused on management issues. The training focused on leadership, management, communication, decision-making and ongoing education is known to help professionals achieve knowledge, skills and attitudes, that is, managerial skills for working in the health sector (3) .
In this study, decision-making is highlighted as a managerial competence of nurses, which can be learned during academic training, in addition to the theoretical field, carrying out a practical approach through realistic simulation, which is considered a methodological strategy that benefits students during undergraduate studies (4) .
Stimulating clinical reasoning and decision-making to perform assertive procedures through simulations improves adverse event prevention, ensuring better nursing care (5) . Certain actions or resolutions, to make a decision, must be chosen based on prior knowledge, since the hospital scenario requires initiatives based on the level of complexity of user care, especially in a short time for assertive choices and deliberations.
Clinical simulation applied to nursing students should favor the development of skills for managerial decisionmaking, making them more active in the face of existing needs during nursing care, as observed in a study with 233 nursing students in central Portugal (6) . Through curricular stimuli required by ministerial decrees, training centers have adopted innovative pedagogical tools, such as realistic simulations for more efficient learning (7)(8)(9) .
Given the above, this study has the following guiding questions: what are the stages of construction and validation of a clinical simulation scenario on managerial decision-making in hospital nurses? and how is the final version of such a scenario to be applied to undergraduate nursing students?
Valid and reliable simulated clinical scenarios should be applied to students through the integration of systematic approaches based on evidence that the participants are aware of (10) , considering the opinion of judges/experts to ensure alignment with existing good practices. This is because previous systematic reviews have shown the effectiveness of simulation as a teaching and learning strategy, important for the development of clinical competence and academic performance (11)(12) .
This study aimed to build and validate a clinical simulation scenario on hospital nurse managerial decisionmaking competence for undergraduate nursing students.

Method Study type
This study is defined as descriptive and methodological and made use of the conceptual model of simulation proposed by Jeffries as a methodological framework. In this model, different elements make up a simulation, such as a theme identification, simulation goals, participants, simulation scenarios and debriefing (13) . Furthermore, this study followed the best-practice standards for simulations published by the International Nursing Association for Clinical Simulation and Learning, with the prebriefing, scenario, and debriefing phases for scenario development in addition to the checklist (14) .
Data structuring followed recommendations in the revised Standards for Quality Improvement Reporting

Data collection location
Data were collected at the Nursing Practice Simulation Center of a Higher Education Institution (HEI) located in the city of Ribeirão Preto -São Paulo State, Brazil. The institution offers two undergraduate nursing courses, one for a Bachelor's degree and another for a Bachelor's and a Teaching degree.

Period
Data collection took place between May 2019 and February 2020.

Population
Judges participated in the elaboration and validation of the scenario. Moreover, nurses and graduate nursing students participated as players to represent the respective scenario.

Selection criteria
The judges were selected by consulting the Curriculum Vitae of researchers, considering academic degrees, years of experience in clinical practice, research carried out in the area of interest of the study, published articles on the subject and participation in events in the field.

Participants
Ten judges took part in the study. Five participated in the online validation of the checklist and the other five participated in the face-to-face validation of the scenario.
These participants comprised professional nurses, teachers and experts in the field of clinical simulation. An odd number of experts, as well as a minimum of three judges, is recommended to assess items related to equivalence and agreement of responses. The experts must have experience and technical/scientific knowledge, besides being able to analyze and judge items related to the scenario, which were selected by convenience sampling (16) .
Two graduate students, a nurse from the Simulation Center of the selected institution, and two researchers/ authors of this research participated in the face-to-face validation of the scenario. These players were chosen based on their previous experience in other simulation activities.

Study variables
There is none.

Instruments used in information collection
Initially, a script of the scenario was prepared and contained information about it. Then, the authors built an instrument to be used by judges, called a checklist. This tool had four domains: prebriefing, scenario in action, debriefing and general assessment for later calculation of the Content Validity Index (CVI).
In a second moment, the face-to-face validation of the scenario was performed during a simulation where the judges used a validated checklist to signal whether actions were taken or not, as they happened, in addition to making suggestions.

Data collection
In the first stage, the checklist used was sent by e-mail to five judges, along with the scenario script, requesting an evaluation and return within 15 days. With this, the researchers could calculate the CVI, using a cutoff point of 0.80 as a minimum to characterize an item as valid. Three aspects were considered for the face-andcontent validity of the checklist, namely: clarity, relevance and appearance. A five-point ordinal Likert scale was used, assigning values from one to five for each item, in which: (5) I totally agree, (4) I agree, (3) neither agree nor disagree, (2) disagree, (1) strongly disagree.
In the second stage, the scenario was validated faceto-face by five other expert judges on the scheduled day and time at the Nursing Practice Simulation Center of the public HEI selected. The checklist was made available to the judges, containing prebriefing, scenario in action and debriefing for scenario validation. Five players participated in the representation of the scenario, with the nurse from the HEI Simulation Center playing the role of doctor and nurse, two graduate nursing students, one as a patient/ client and the other as a nurse, while the scenario was conducted by two researchers/research authors. The players were explained the scenario stages and, before their performance, they were given the checklist so that they could become familiar with each simulation stage. Guidelines were also provided on the clinical case, research goals, materials and equipment available and presentation of the environment.

Data processing and analysis
Data related to the face and content validation of the instrument was analyzed by calculating the Content Validity Index (CVI) (17) , which shows the congruence of the expert judges' opinions through the proportion of agreement on the scenario simulation questions that had been validated.
The CVI was calculated considering the acceptable agreement rate among the members of the expert committee, which must be at least 80% and, preferably, above 90% (18) . AC1 statistic was used to assess the agreement between the judges for each item describing the scenario in the checklist, regarding the criteria of clarity, appearance and relevance (19) .
The agreement analysis was performed using the R Core Team software (20)

Ethical aspects
In compliance with the requirements of Resolution  To improve the scenario, the guidelines issued by the judges were considered, making it clearer and easier to understand and facilitating its replication for students.
Thus, some items were reformulated and, in the end, for the Scenario in Action domain, 18 items remained, as shown in Figure 2. Facilitator invites two students to participate in the scenario

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Facilitator presents the scenario's general objectives for all players and students 6 Facilitator presents maximum scenario time to participating players and students 7 The scenario is presented to participating students, providing time for familiarization with the environment and material resources available to players/students  As shown in Figure 1, considering the 10 items initially evaluated for clarity, relevance, and appearance in the prebriefing, 73.33% of them had a CVI above 80%, ranging from 60 to 100%. CVIs were below 80% on two items for appearance, three for agreement, and two for relevance. Still, according to the average CVI (a validated index of agreement between the judges for the total content of each question), four items had an average CVI of less than 80%, ranging from 60 to 73.3%. Therefore, to adapt according to the judges' criteria, we decided to restructure the instrument, whose prebriefing domain was reduced from 10 to seven items.
Next, Figure 1 shows the prebriefing domain of the final version of the instrument, which was used by the judges during scenario validation.

Domain description Item Specification
Debriefing 1 Facilitator reiterates the simulation purpose to the group 2 Facilitator invites players to reflect on how they felt acting in the scenario and identify the type of scenario proposed according to the theme 3 Facilitator encourages viewers to raise positive aspects of student's performances in the scenario 4 Facilitator encourages participants to reflect on potential practices different from those performed (starting with those who participated in the scenario)

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Facilitator discourages destructive criticism if any 6 Facilitator stimulates students on important aspects of decision-making competence, articulating theory and practice 7 Facilitator encourages students to suggest other decision-making possibilities that were not presented in the scenario performed   Prebriefing: Facilitator introduces himself to students, establishes a confidentiality agreement and invites two students to participate in the scenario, presents general goals of the scenario to all participants, presents maximum time for the scenario execution, making time available for participants to recognize the environment and material resources.

Development of the scenario in action:
Facilitator presents the clinical case and details the situation to everyone. Patient J.C.M, 65 years old, on the third day of admission to the medical clinic with a diagnosis of community-acquired pneumonia and systemic arterial hypertension (SAH). The lifestyle factors smoking and sedentarism were referred to. She is conscious, and oriented and does not require help to walk. There is a medical prescription and nursing evolution in the patient's chart. The unit's daily staff includes one nursing technician (nursing student) responsible for the direct care of the patient whose initials are J.C.M., it also includes one nurse (student) responsible for the hospital unit, in addition to a physician on duty who can be reached by phone.  Thus, the final version of the simulation scenario to be applied to nursing students includes the three domains: prebriefing, scenario in action and debriefing, as well as their respective elements (Figures 4 and 5).

Discussion
To build scenarios, systematization and careful planning should be considered, in addition to the use of tools to instrumentalize professor/facilitator activity (7)(8)(9)(10) .
The proposed scenario brought a real clinical situation, seeking to emphasize the importance of managerial decision-making and its practice by undergraduate nursing students. This way, as future professionals, they will be able to act with critical and reflective thinking about the best practice to be established in the work environment.
Therefore, the importance of a previous experience through validated clinical scenarios is here emphasized. duration time and scenario, among others (13) .
For that purpose, a favorable environment must be created, wherein errors are considered opportunities to Expected actions: A: Assess airways; B: Check RR * , elevate the head of the bed; C: Perform non-invasive blood pressure measurement and HR check † ; D: Assess the level of consciousness; E: Check peripheral venous access and measure body temperature. Others: Assess the patient's general conditions (interview and physical examination); Implement safe medication administration practices and verify the nine rights of medication administration#; Contact the previous shift nurse responsible for the patient for information on the adverse even through a telephone call; Communicate the fact to the doctor (who is reached by phone), check for potential adjustment of antihypertensive medication schedule and administer the medication according to medical advice, double-checking the medical record; Advise the patient about the complication and which course of action will be taken; Record the activities performed in the medical record.  improve, exercising the simulated practice; therefore, at this stage, strategies to develop greater interaction between participants should be sought, increasing their participation (24) .
During the scenario development stage, participants had to be informed about the progress of the clinical case, as well as the user's conditions and previous history so that they could understand the care priorities. Thus, participants in clinical simulations must be guided in a planned way (25) .
The last stage of scenario development, the debriefing, was the domain that received the best evaluation from judges. This step is essential for students to apply theoretical learning in practice, enabling them to solve problems and make the most appropriate clinical decisions (26) . Thus, learning decision-making competence is related to acting and leads nursing students to acquire knowledge and develop other global competencies, leading to a practice of excellence (27) .
During the debriefing, the discussion addressed Finally, at this stage, the nursing team should be permanently educated on safe medication administration practices since they are known to be a concern among the care activities, with vulnerabilities being identified in the process, making it inappropriate and hence undesirable (28) .
Realistic simulations must go beyond technical skills but include non-technical skills (29) , which include managerial skills such as decision-making by nurses, simulations is believed to be more difficult to forget, thus improving students' professional performance. Simulations also increase student confidence and satisfaction by being conducted in a controlled and protected environment. This environment seeks to approach scenarios closer to reality, allowing error correction. Therefore, simulation is an important teaching method in undergraduate healthcare programs, especially in nursing (30) .
Because of the above, it is emphasized that instruments and clinical scenarios must be validated with experts on the subject, that is, specialists must present agreement or disagreement for each stage of the scenario before its use.
The approach to undergraduate teaching methods must be constant and standardized, and simulations must always seek new knowledge. The use of simulation in nursing teaching-learning contributes to the development of cognitive and technical skills capable of transforming the teaching process and, consequently, the professional training of nurses (31) .
The results of education through simulation are positive, but how simulations are structured and conducted is variable, showing that validated instruments are little used (13) . Developed scenarios should be validated because, if they are little clear or reliable, their replication by other educators and researchers is hindered (32) . There are countless benefits of implementing teaching strategies by active methods, in which high technology is not always necessary to ensure learning success. This is because the financial difficulties of educational institutions must be overcome so that simulations could achieve good results (33) .
As it was developed and validated in a specific hospital area, the scenario in this study was identified as limited, restricting its use in other health care sectors although nurse managerial decision-making is one of their essential skills in the work process.
Concerning nursing, this study brings advances to scientific knowledge since it is innovative. Here, undergraduate nursing courses have the opportunity to use with students a validated scenario focused on managerial decision-making and thus optimize their knowledge based on a realistic experience. Furthermore, this scenario can contribute to an expanded view of the nursing work process, which goes beyond assistance, Ribeiro NM, Leal LA, Ferreira MVF, Chaves LDP, Ignácio DS, Henriques SH.
bringing decision-making as a process that requires extensive knowledge to solve it.

Conclusion
Managerial decision-making is a competence of hospital nurses in their daily work, which makes them professionals in great demand to solve problems in the unit and care provided to users. In this context, the use of clinical simulation as a teaching and learning strategy for nursing students, anticipating probable real situations that involve decision-making, provides relevant skills for their professional practice as future nurses.
In this direction, the clinical simulation scenario proposed in this study included the steps required for its construction and validation. It, thus, has become viable and can be used by higher education institutions, to develop managerial decision-making competence for nursing students.